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SANJOAQUIN Environmental Health Department <br /> COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # <br /> A <br /> C Facility Name A&A Gas & Food Mart Phone # 209-466-9516 <br /> I <br /> L Address 16 E . Harding Way, Stockton , CA 95204 <br /> 1 Cross Street Harding Way and Center St, <br /> T <br /> Y Owner/Operator Ali Hussaini Phone # 209-466-9516 <br /> C Contractor Name ECO-CHEK Compliance , Inc. Phone # 925499-6294 <br /> 0 <br /> T Contractor Address P . O . Box 3294 Lafayette , CA 94549 CA Lic # 958763 Class A <br /> A Insurer Work Comp # 1942346-23 <br /> cICC Technician ' s Name Marco Ale os Expiration Date <br /> T 1 p 03/17/2025 <br /> 0 ICC Installer' s Name Expiration Date <br /> R Marco Alejos p � 03/17/2025 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1 /2, etc. ) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L <br /> A (See Attachment With Conditions ) <br /> N Plan Reviewers Name a �GYI Date 3 / 2-! <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES , STATE LAWS , AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING : "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED , I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA. " CONTRACTOR 'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING : "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK F H THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER 'S COMPENSATION LAWS <br /> OF CALIFORNIA." / <br /> Applicant's Signature ( Title Compliance Operations Associate Date 03/07/2024 <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e . g . property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Cindy Cadacio-Chan TITLE Compliance Operations Associate PHONE # 925-499-6294 <br /> ADDRESS P . O . Box 1394 , Lafayette , CA 94549 <br /> SIGNATURE DATE 03/07/2024 <br /> 2of6 <br />